Diarrhoea can occur due to any of the numerous aetiologies, which include infectious, drug-induced, food related, surgical, inflammatory, transit-related or malabsorption. Four mechanisms have been implicated in diarrhoea: increased osmotic load, increased secretion, inflammation and decreased absorption time. Diarrhoea can result in fluid loss with consequent dehydration, electrolyte loss (Na+, K+, Mg2+, Cl–) and even vascular collapse. Loss of bicarbonate ions can lead to a metabolic acidosis.

In an emergency, where consent cannot be obtained, doctors should provide medical treatment that is in the patient’s best interests and is immediately necessary to save a life or avoid significant deterioration in the patient’s health. There is clearly insufficient time here to apply to a court. The GMC and common law advises that emergency life saving treatment can be given to a child irrespective of the parents views.

Alveolar ventilation = respiratory rate × (tidal volume − anatomical dead space volume). Increase in respiratory rate simply causes movement of air in the anatomical dead space, with no contribution to the alveolar ventilation. By use of a shorter snorkel, the effective anatomical dead space will decrease and will cause a maximum rise in alveolar ventilation along with doubling of tidal volume.

Increased alkaline phosphatase is indicative of cholestasis, with a 4x or greater increase seen 1-2 days after biliary obstruction. Its level can remain elevated several days after the obstruction is resolved due to the long half life (7 days). Increase up to three times the normal level can be seen in hepatitis, cirrhosis, space-occupying lesions and infiltrative disorders. Raised alkaline phosphatase with other liver function tests being normal can occur in focal hepatic lesions like abscesses or tumours, or in partial/intermittent biliary obstruction. However, alkaline phosphatase has several isoenzymes, which originate in different organs, particularly bone. An isolated rise can also be seen in malignancies (bronchogenic carcinoma, Hodgkin’s lymphoma), post-fatty meals (from the small intestine), in pregnancy (from the placenta), in growing children (from bone growth) and in chronic renal failure (from intestine and bone). One can differentiate between hepatic and non-hepatic cause by measurement of enzymes specific to the liver e.g. gamma-glutamyl transferase (GGT).
In an elderly, asymptomatic patient, isolated rise of alkaline phosphatase usually points to bone disease (like Paget’s disease). Presence of other symptoms such as jaundice, pale stools, weight loss suggests obstructive jaundice, most probably due to pancreatic carcinoma.

Formation of granulation tissue at the periphery of the hematoma is a normal process leading to resolution. This granulation tissue is composed of new capillaries, fibroblasts and collagen. Lysis of a blood clot can occur, but the actual process of this response is known as organization, wherein the scar tissue will become part of the vessels. This is followed by recanalization and embolization which can lead to eventual complications. Proliferation of a clot will occur due to an imbalance in the clotting and lysing systems. Thrombosis has nothing to do with the process described above.

Findings described are suggestive of Waterhouse-Friderichsen syndrome which develops secondary to meningococcaemia. The reported incidence of Addison’s disease is 4 in 100,000. It affects both sexes equally and is seen in all age groups. It tends to show clinical symptoms at the time of metabolic stress or trauma. The symptoms are precipitated by acute infections, trauma, surgery or sodium loss due to excessive perspiration.

A below-knee amputation (“BKA”) is a transtibial amputation that involves removing the foot, ankle joint, and distal tibia and fibula with related soft tissue structures. In general, a BKA is preferred over an above-knee amputation (AKA), as the former has better rehabilitation and functional outcomes. There are three major categories of indications for proceeding with a BKA. These include:
– Urgent cases where source control of necrotizing infections or haemorrhagic injuries outweighs limb preservation.
– Less acutely, urgent BKAs may be performed for chronic nonhealing ulcers or significant infections with the risk of impending systemic infection or sepsis.
– Urgent BKAs may be performed where limb salvage has failed to preserve a mangled lower extremity. Adequate resuscitation and stabilization must always have occurred before such a decision, as judged by vital signs, lactate, base deficit, and the management of concomitant injuries.
This man is hemodynamically unstable and the limb is likely to be non-viable after so many hours of entrapment. Hence, the safest option would be primary amputation of the injured limb.

Bronchial carcinoids are neuroendocrine tumours that arise from Kulchitsky’s cells of the bronchial epithelium. Kulchitsky’s cells belong to the diffuse endocrine system. Patients affected by this tumour may be asymptomatic or may present with symptoms of airway obstruction, like dyspnoea, wheezing, and cough. Other common findings are recurrent pneumonia, haemoptysis, chest pain and paraneoplastic syndromes. Chest radiographs are abnormal in the majority of cases. Peripheral carcinoids usually present as a solitary pulmonary nodule. For central lesions common findings include hilar or perihilar masses with or without atelectasis, bronchiectasis, or consolidation. Bronchial carcinoids most commonly arise in the large bronchi causing obstruction.

Unlike other cancers for which a biopsy is performed, when testicular cancer is suspected the entire testicle is removed in a procedure called an orchiectomy through an incision in the groin and pulling the testicle up from the scrotum. A biopsy through the scrotum for testicular cancer runs the risk of spreading the cancer, and can complicate future treatment options. Removing the entire testicle out of the scrotum is the only safe way to diagnose for testicular cancer. Only the cancer-containing testicle is removed, and it is important to do so promptly.
If there is any uncertainty, the urologists can examine the testicle by pulling the testicle out of the scrotum; if a condition other than testis cancer is found, the testicle is placed back into the scrotum.

Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours.

There are eight carpal bones which are arranged in two rows, proximal and distal; scaphoid, lunate, triquetral and pisiform are of proximal row. Trapezium, trapezoid, capitate and hamate are of the distal row.

Boerhaave syndrome refers to an oesophageal rupture secondary to forceful vomiting and retching. They are often associated with the clinical triad (Mackler’s triad) of vomiting, chest pain and subcutaneous emphysema. Other symptoms include epigastric pain, back pain, dyspnoea and shock. This condition was universally fatal before the age of surgery.

Ideal management for Boerhaave syndrome involves a combination of both conservative and surgical interventions.

Mainstays of therapy include the following:
– Intravenous volume resuscitation
– Administration of broad-spectrum antibiotics
– Prompt endoscopic and/or surgical intervention

The optic foramen is the opening to the optic canal. The canal is located in the sphenoid bone; it is bounded medially by the body of the sphenoid and laterally by the lesser wing of the sphenoid. The superior surface of the sphenoid bone is bounded behind by a ridge, which forms the anterior border of a narrow, transverse groove, the chiasmatic groove (optic groove). The groove ends on either side in the optic foramen, which transmits the optic nerve and ophthalmic artery into the orbital cavity. Compared to the optic nerve, the ophthalmic artery is located inferolaterally within the canal.

The intragastric balloon aids weight loss by slowing the rate at which food enters the stomach and by stimulating gastric stretch receptors. But lifestyle changes, including behaviour modification, exercise and a healthy diet, are crucial for maintaining weight loss once the device is removed. Intragastric balloon is really only suitable as a bridge to a more definitive surgical solution and is associated with a high failure rates and complications.

Gastric banding: band applied to upper stomach which can be inflated or deflated with normal saline. This affects satiety. Over a 5 year period complications requiring further surgery occur in up to 15% cases.

Roux-en-Y gastric bypass: a gastric pouch is formed and connected to the jejunum. Patients achieve greater and more long-term weight loss than gastric banding.

Sleeve gastrectomy: body and fundus resected to leave a small section of stomach

The presence of atypical cells in urinalysis without findings in the bladder suggests a lesion located higher up, most probably in ureters or renal pelvis. Transitional cell cancer of the renal pelvis is a disease in which malignant cells form in the renal pelvis and is characterised by the presence of abnormal cells in urine cytology.

The patient is in hypovolemic shock, he is transfused with blood to replace the volume lost. It is important not only to replace fluids but stop active bleeding in resuscitation. Fluid replacement will result in a decreased sympathetic discharge and adequate ventricular filling thus reducing total peripheral resistance and increasing cardiac output and cardiac filling pressures.

Hartmann’s solution is the preferred fluid among the listed options.

In UK, Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) and The National Institute for Health and Care Excellence (NICE) guidelines were devised to try and develop a consensus on how to administer intravenous fluids (IV) postoperatively. A decade ago, it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline, and many oliguric postoperative patients received enormous quantities of IV fluids. As a result, they developed hyperchloraemic acidosis. With greater understanding of this potential complication, the use of electrolyte-balanced solutions (Hartmann’s or Ringer Lactate solution) is now favoured over normal saline.

The guidelines further include:
1. Fluids given should be documented clearly.
2. Assess the patient’s fluid status when they leave the theatre.
3. If the patient is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible.
4. If the patient is oedematous, hypovolaemia if present should be treated first. This should then be followed by a negative balance of sodium and water, monitored closely.
5. Solutions such as Dextran 70 should be cautiously used in patients with sepsis as there is a risk of developing acute renal injury.

Scurvy is a condition caused by a dietary deficiency of vitamin C, also known as ascorbic acid. Humans are unable to synthesize vitamin C, therefore the quantity of it that the body needs has to come from the diet. The presence of an adequate quantity of vitamin C is required for normal collagen synthesis. In scurvy bleeding tendency is due to capillary fragility and not coagulation defects, therefore blood tests are normal.

The long thoracic nerve supplies the serratus anterior muscle. When this nerve is injured the muscle undergoes paralysis, which is seen clinically as winging of the scapula most apparent when the arm is lifted forward. The long thoracic nerve is greatly susceptible to injury during breast surgery because of its long and superficial course along the thorax from its origin, the brachial plexus, to the lower border of the serratus anterior muscle.

A rib tubercle is a projection that is postero-inferior and lateral to the neck of a rib which articulates with the transverse process of the corresponding vertebra i.e. of the same number. Therefore, the tubercle of rib 7 articulates with the transverse process of T7 vertebra. The head of the rib 7, on the other hand, articulates with the 6th vertebra superiorly and the 7th vertebra inferiorly.

The inferior thyroid artery is an artery in the neck. It arises from the thyrocervical trunk and passes upward, in front of the vertebral artery and longus colli muscle.

The anterior drawer test is an important orthopaedic test that is used to test weakness of the anterior cruciate ligament. The test is done by having the patient sit in a supine position with his/her knees flexed at 90 degrees. An examiner stabilises the patients feet and softly pulls or pushes on the proximal tibia. The test is positive if there is translational movement of the tibia in relation to the femur, indicating a weakened anterior cruciate ligament. The anterior cruciate ligament prevents the tibia from sliding out in front of the femur.

The most likely vascular structure is the inferior vena cava. The inferior vena cava is formed by the joining of the two common iliac arteries, the right and the left iliac artery, at the level of the fifth lumbar vertebra( L5). The inferior vena cava passes along the right side of the vertebral column. It enters the thoracic cavity into the underside of the heart through the caval opening of the diaphragm at the level of the eight thoracic vertebra (T8).

A pressure of 10 mmHg should be set on the gas insufflation system.

Laparoscopic surgery may be performed in a number of body cavities. In some areas, irrigation solutions are preferred. In the abdomen, however, insufflation with carbon dioxide gas is commonly used. The amount of gas delivered is adjusted to maintain a constant intra-abdominal pressure of 12–15 mmHg. Excessive intra-abdominal pressure may reduce venous return and lead to hypotension. Too little insufflation will risk obscuring the surgical view.

A foreign body reaction Is characteristic of giant cells. Glass being the foreign object initiates an inflammatory response in this condition.
Mast cells are involved in allergic reactions.
Eosinophils are characteristic of a parasitic infection and allergic inflammatory process but are not due to foreign bodies.
Plasma cells are typical of chronic inflammation.
Lymphocytes are involved in viral infections.
Macrophages combine together to form giant cells.

Answer: Bochdalek hernia

A Bochdalek hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni hernia. A Bochdalek hernia is a congenital abnormality in which an opening exists in the infant’s diaphragm, allowing normally intra-abdominal organs (particularly the stomach and intestines) to protrude into the thoracic cavity. In the majority of patients, the affected lung will be deformed, and the resulting lung compression can be life-threatening. Bochdalek hernias occur more commonly on the posterior left side (85%, versus right side 15%).

In normal Bochdalek hernia cases, the symptoms are often observable simultaneously with the baby’s birth. A few of the symptoms of a Bochdalek Hernia include difficulty breathing, fast respiration and increased heart rate. Also, if the baby appears to have cyanosis (blue-tinted skin) this can also be a sign. Another way to differentiate a healthy baby from a baby with Bochdalek Hernia, is to look at the chest immediately after birth. If the baby has a Bochdalek Hernia it may appear that one side of the chest cavity is larger than the other and or the abdomen seems to be scaphoid (caved in).

Situs inversus (also called situs transversus or oppositus) is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions. The normal arrangement of internal organs is known as situs solitus while situs inversus is generally the mirror image of situs solitus. Although cardiac problems are more common than in the general population, most people with situs inversus have no medical symptoms or complications resulting from the condition, and until the advent of modern medicine it was usually undiagnosed. In the absence of congenital heart defects, individuals with situs inversus are homeostatically normal, and can live standard healthy lives, without any complications related to their medical condition. There is a 5–10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels. The incidence of congenital heart disease is 95% in situs inversus with levocardia.

Cystic fibrosis is a progressive, genetic disease that causes persistent lung infections and limits the ability to breathe over time. In people with CF, mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene cause the CFTR protein to become dysfunctional. When the protein is not working correctly, it’s unable to help move chloride — a component of salt — to the cell surface. Without the chloride to attract water to the cell surface, the mucus in various organs becomes thick and sticky. In the lungs, the mucus clogs the airways and traps germs, like bacteria, leading to infections, inflammation, respiratory failure, and other complications.

Necrotizing enterocolitis (NEC) is a medical condition where a portion of the bowel dies. It typically occurs in new-borns that are either premature or otherwise unwell. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile.
The exact cause is unclear. Risk factors include congenital heart disease, birth asphyxia, exchange transfusion, and premature rupture of membranes. The underlying mechanism is believed to involve a combination of poor blood flow and infection of the intestines. Diagnosis is based on symptoms and confirmed with medical imaging.

Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and is characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
-anterior
-more often right-sided (,90%)
-small
-rare (,2% of CDH)
-at low risk of prolapse

Only ,30% of patients are symptomatic. New-borns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.

Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:

Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or both
Late diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction
Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction
Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.

The flattened appearance of the face is a classical description of the dish-face deformity associated with Le Fort III fracture of the midface.

The term Le Fort fractures is applied to transverse fractures of the midface involving the maxillary bone and surrounding structures in either a horizontal, pyramidal, or transverse direction. There are three grades of Le Fort fractures:

1. Le Fort I
It is the horizontal fracture of the maxilla. Violent force over a more extensive area above the level of the
teeth will result in this type of fracture. Horizontal fracture line is seen above the apices of the maxillary teeth, detaching the tooth-bearing portion of the maxilla from the rest of the facial skeleton. Floating maxilla and Guerin’s sign is seen in such patients.

2. Le Fort II
It is a pyramidal or subzygomatic fracture. Violent force in the central region extending from glabella to the alveolus results in this type of fracture, resulting in ballooning or moon-face facial deformity.

3. Le Fort III
It is a high-level transverse or suprazygomatic fracture associated with craniofacial disjunction. The entire facial skeleton moves as a single block as a result of the trauma. The patient develops a characteristic panda facies and dish-face deformity.

The pectineus is supplied by the second, third and fourth lumbar nerves through the femoral nerve and by the third lumbar through the accessory obturator when it exists. The anterior surface of the thigh receives its innervation from the femoral nerve as well, thus this is the nerve most likely to be injured

The ilioinguinal nerve arises together with the iliohypogastric nerve from the first lumbar nerve to emerge from the lateral border of the psoas major muscle just below the iliohypogastric and passing obliquely across the quadratus lumborum and iliacus muscles. It perforates the transversus abdominis, near the anterior part of the iliac crest and communicates with the iliohypogastric nerve between the internal oblique and the transversus. It then pierces the internal oblique to distribute filaments to it and accompanying the spermatic cord through the subcutaneous inguinal ring, is distributed to the skin of the upper and medial parts of the thigh, the skin over the root of the penis and the upper part of the scrotum in man and to the skin covering the mons pubis and labium majus in the woman. As the ilioinguinal nerve runs through the inguinal canal, it could easily be compressed by a hernial sac.
The femoral branch of genitofemoral nerve provides sensory innervation of the upper medial thigh.
The femoral nerve innervates the compartment of the thigh and also has some cutaneous sensory branches to the thigh.
The iliohypogastric nerve innervates the skin of the lower abdominal wall, upper hip and upper thigh. The subcostal nerve innervates the skin of the anterolateral abdominal wall and the anterior scrotal nerve is a terminal branch of the ilioinguinal nerve.

The central retinal artery supplies all the nerve fibres that form the optic nerve, which carries the visual information to the lateral geniculate nucleus of the thalamus. Thus if the central retinal artery gets occluded, there is complete loss of vision in that eye and the entire retina (with the exception of the fovea) becomes pale, swollen and opaque while the central fovea still appears reddish (this is because the choroid colour shows through). This is the basis of the famous Cherry red spot seen on examination of the retina on fundoscopy of a central retinal artery occlusion (CRAO).

Angio-oedema, is the rapid swelling of the skin, mucosa and submucosal tissues. The underlying mechanism typically involves histamine or bradykinin. The version related to histamine is to due an allergic reaction to agents such as insect bites, food, or medications. The version related to bradykinin may occur due to an inherited C1 esterase inhibitor deficiency, medications e.g. angiotensin converting enzyme inhibitors, or a lymphoproliferative disorder.